Introduction:
Children constitute important position in every country. Their mortality status reflects the country’s overall development. 6.6 million Children under age five died globally in 2012, nearly 18 000 every day. Mortality rate of children under five years in India in 2012 was 56/1000 live births compared to world average of 34.9/1000 live births. The most common direct causes of mortality in children below five years in India are diarrhoea, measles and pneumonia. Malnutrition is the underlying cause of many under-five deaths. Child survival in India varies significantly across states, geographic location and socio-economic factors, reflecting uneven development in the country and inequalities in many aspects of life. It needs to reduce under-five mortality to 39 per thousand live births by 2015 to meet Millennium Development Goal (MDG) 4. While progress has been made, it is unequally distributed between states and region and remains insufficient to reach MDG 4 by 2015.(1)
According to a Save the Children paper, children from the poorest households in India are three times more likely to die before their fifth birthday than those from the richest households.(2) It is now widely recognized that cultural factors are deeply involved in all affairs of man, including health and sickness. Understanding human behaviour is a prerequisite to change behaviour and improve health practices.(3)
Further, fishermen community possesses unique characteristics of a folk society despite the urban environment around it, and remains homogeneous in social, economic and cultural matters. Since major portion of the life of fishermen is spent at sea, women assume a vital place with regard to the upbringing of the children and in the household. No study was done so far to assess the health seeking behavior in fishermen community in Tamil Nadu. Therefore, this study was planned to explore the health seeking behavior on child care among fishermen community in Tamil Nadu.
Operational definitions
Healthcare-seeking Practice: Any activity undertaken by individuals who perceive themselves or their children to have a health problem for the purpose of finding a remedy. This is based on the recognition of symptoms, which are interpreted by individuals who then proceed to address the problems.(4)
Immunization status
v Immunized up to date: Child who had received all doses of vaccine for which he/she was eligible by age according to National Immunization Schedule.
v Immunized incompletely: Child had not fully immunized but received only one or two doses of vaccine for his/her age as per National Immunization Schedule.
v Un-immunized: A child who had not yet received any vaccine for the age according to National Immunization Schedule.(5)
Integrated Child Development Services (ICDS) is a central government scheme which provides supplementary nutrition, non formal education, immunization services, regular growth monitoring, and deworming services for preschool children.(6)
Acute Diarrhea Disease (ADD) - It is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual.(7)
Acute Respiratory Illness (ARI) – Child who had any of the symptoms of blocked or runny nose, cough, difficulty in breathing or fast breathing in the previous six months.(7)
Materials and Methods:
This was a descriptive cross sectional study conducted among 260 parents of children less than five years of age in fishermen community with six months recall period in Kovalm village, Kancheepuram District, Tamil Nadu during May to October, 2014 using a pretested semi-structured questionnaire. The sample size was calculated on the basis of 63% of children with childhood diseases was taken to a health facility or provider for diarrhoea according to NFHS-3 survey.(8) With allowable error 10%, sample size calculation came to 260.
List of children under five years in Kovalam fishermen village was obtained from village health nurse. There were 512 children of age group less than five years in Kovalam village. Line listing of all the children less than five years of age group was prepared and the required sample size of 260 was derived by simple random sampling method using computer generated random number table.
Pre-tested semi-structured questionnaire was used. It was translated to local language Tamil while interviewing the participants. Parents of the randomly selected children were administered questionnaire in local Tamil language. Details of their socio demographic data was asked in part I of the questionnaire, part II consisted of questions assessing the child immunization status and health seeking behaviour on common child hood illnesses in the preceding six months period.
Ethical committee permission was obtained. After getting informed consent from the participant, the respondents were administered questionnaire through face to face interview method. Data was entered in excel format and analyzed using SPSS 18 software. Descriptive statistics such as frequencies and percentages were used for analysis. Chi square test was used to check the test of significant between associated factors. P value of 0.05 was taken as statistically significant.
Results
All the respondents were mothers with mean age of 25.68 years, range 18 to 35 years and with standard deviation of 4.56, majority (45.38%) of the respondents were of age in between 26 to 35 years. Mean age of the father was 38.65, range of 22 to 50 and standard deviation of 9.09 and the occupation of the fathers were fishing. Nearly three fourth (76.54%) of the mothers were home maker and living (79.23%) in a nuclear family. Majority were Hindus (95.77%) and with two children (59.23%) as shown in Table 1. According to modified B.G. Prasad classification, all of them (96.54%) fall under class III socio economic classification.(9)
| Table 1: Socio-demographic profile of the parents (N=260) |
Variable |
Frequency (%) |
Age of the parents |
Mother |
Father |
20 years and less |
29(11.15%) |
- |
21-25 years |
113(43.46%) |
24(9.23%) |
26-35 years |
118(45.38%) |
75(28.85%) |
36-45 years |
- |
91(35.00%) |
46 and above |
- |
70(26.92%) |
Educational status of the parents |
Illiterate |
22(8.46%) |
30(11.54%) |
Primary school |
60(23.08%) |
109(41.92%) |
Middle school |
65(25.00%) |
84(32.31%) |
High school |
64(24.62%) |
27(10.38%) |
Higher secondary |
35(13.46%) |
10(3.85%) |
Graduate and above |
14(5.38%) |
- |
Type of family |
Nuclear |
206(79.23%) |
Joint |
54(20.77%) |
Total no. of children |
1 |
84(32.31%) |
2 |
154(59.23%) |
3 |
21(8.08%) |
4 |
1(0.38%) |
Religion |
Hindus |
249(95.77%) |
Muslims |
10(3.85%) |
Christians |
1(0.38%) |
Occupation of the mother |
Home maker |
199(76.54%) |
Skilled |
36(13.85%) |
Semi-skilled/unskilled |
16(6.15%) |
Clerk/shop owner |
8(3.08%) |
Professional/semi-professional |
1(0.38%) |
Analysis of the study population (children under five years of age) revealed that nearly half of them were male (55%) and of first order (56.92%), mean age of the study population was 31.07 months, range of 7 to 60 months with standard deviation of 13.06 and 35% were in the age group in between 13 to 24 months (Table 2).
| Table 2: Basic details of the child (N-260) |
Variable |
Frequency (%) |
Sex |
Male |
143(55.00%) |
Female |
117(45.00%) |
Age in months |
7-12 months |
7(2.69%) |
13-24 months |
91(35.00%) |
25-36 months |
73(28.08%) |
37-48 months |
53(20.38%) |
49-60 months |
36(13.85%) |
Order of birth |
1 |
148(56.92%) |
2 |
100(38.46%) |
3 |
11(4.23%) |
4 |
1(0.38%) |
Among the study population of 260 under five children, 82.69% were registered in Integrated Child Development Scheme (ICDS) and regular growth assessment was done for 65.76% of the study group in ICDS, and 34.24% in private clinic in their locality. About 68.65% were getting at least one or some kind of services from ICDS. About 98.08% of the mothers were having immunization card for their child. Majority of the children (68.85%) were given vaccination in the ICDS center which was given through village health nurse attached to the local primary health center and 1.54% were unimmunized. Nearly three fourth of them (81.15%) were consulting private doctors for their child illness (Table 3).
| Table 3: Health care seeking behavior of the parents (N-260) |
Health care information |
No. of the respondents (%) |
Immunization status |
Immunized up to date |
245(94.23%) |
Incompletely immunized |
11(4.23%) |
Unimmunized for age |
4(1.54%) |
Place of vaccination |
Primary Health centers |
42(16.15%) |
Anganwadi centers |
179(68.85%) |
Private hospitals |
35(13.46%) |
Unimmunized |
4(1.54%) |
Usual place of consultation during illness |
Government facilities |
49(18.85%) |
Private hospitals |
211(81.15%) |
Total |
260(100%) |
Allopathy medicine was the preferred system of medicine among all the mothers of the study population. Major reason for choosing government facility was cost effectiveness (97.96%) and least reason was good treatment (2.04%). Geographical distance (75.36%), good treatment (14.22%) and time convenience (10.43%) were the reasons given for choosing private health facility.
Among the vaccinated children (n-256), 95.7% of the children were vaccinated at scheduled time period and for 4.3% of them it was delayed. Major reason cited by the mothers for delay in vaccinations were sickness (36.36%) of the child, lack of awareness on time schedule of vaccination (27.27%), family issues (18.18%) and unavailability in the town (18.18%). Only reason mentioned by the mothers of those children who were not immunized (n-4) was ignorance (100%) for not immunizing their children.
Health seeking behaviors like preference for type of health facility and time interval for seeking health care were not significantly associated with any of their socio-demographic variables (Table 4 & 5).
| Table 4: Health seeking behaviour and socio-demographic details of the family (n-260) |
Variable |
Type of health facility opted |
Total
(n-260) |
Chi-square test |
Government (n-49) |
Private (n-211) |
|
|
Age of the mother |
|
|
|
χ2=0.577, p-0.939, d.f=1 |
18-25years |
27(19.01%) |
115(80.99%) |
142(54.62%) |
26-35 years |
22(18.64%) |
96(81.36%) |
118(45.38%) |
Age of the father |
|
|
|
χ2=0.585, p-0.444, d.f=1 |
< 35 years |
21(21.21%) |
78(78.79%) |
99(38.08%) |
36 and above |
28(17.39%) |
133(82.61%) |
161(61.92%) |
Education of mother |
|
|
|
χ2=0.54, p-0.463, d.f=1 |
Till middle school |
30(20.41%) |
117(79.59%) |
147(56.54%) |
High school and above |
19(16.81%) |
94(83.19%) |
113(43.46%) |
Education of the father |
|
|
|
χ2=3.40, p-0.065, d.f=1 |
Till primary school |
32(23.02%) |
107(76.98%) |
139(53.46%) |
Middle school and above |
17(14.05%) |
104(85.95%) |
121(46.54%) |
Occupation of the mother |
|
|
|
χ2=0.356, p-0.85, d.f=1 |
Home maker |
37(18.59%) |
162(81.41%) |
199(76.54%) |
Employed |
12(19.67%) |
49(80.33%) |
61(23.46%) |
Type of family |
|
|
|
χ2=0.478, p-0.945, d.f=1 |
Nuclear |
39(18.93%) |
167(81.07%) |
206(79.23%) |
Joint |
10(18.52%) |
44(81.48%) |
54(20.77%) |
Religion |
|
|
|
χ2=0.533, p-0.465, d.f=1 |
Hindus |
46(18.47%) |
203(81.53%) |
249(95.77%) |
Non-Hindus |
3(27.27%) |
8(72.73%) |
11(4.23%) |
Total no. of children |
|
|
|
χ2=1.5, p-0.221, d.f=1 |
Two and less |
47(19.75%) |
191(80.25%) |
238(91.54%) |
Three and above |
2(9.09%) |
20(90.91%) |
22(8.46%) |
Sex of the child |
|
|
|
χ2=0.917, p-0.762, d.f=1 |
Male |
26(18.18%) |
117(81.82%) |
143(55.00%) |
Female |
23(19.66%) |
94(80.34%) |
117(45.00%) |
Age in months |
|
|
|
χ2=0.896, p-0.765, d.f=1 |
24 months and below |
19(19.39%) |
79(80.61%) |
98(37.69%) |
25-60 months |
29(17.90%) |
133(82.10%) |
162(62.31%) |
Order of birth |
|
|
|
χ2=0.858, p-0.354, d.f=1 |
1st order |
25(16.89%) |
123(83.11%) |
148(56.92%) |
2nd order and above |
24(21.43%) |
88(78.57%) |
112(43.08%) |
| Table 5: Time interval in seeking health care and socio-demographic details of the family |
Variable |
Time interval in seeking health care |
Total
(n-260) |
Chi-square test |
Immediate care (n-237) |
Sought care within 1-2 days (n-23) |
Age of the mother |
|
|
|
χ2=0.469, p-0.493, d.f=1 |
18-25years |
131(92.25%) |
11(7.75%) |
142(54.62%) |
26-35 years |
106(89.83%) |
12(10.17%) |
118(45.38%) |
Age of the father |
|
|
|
χ2=0.116, p-0.733, d.f=1 |
< 35 years |
91(91.92%) |
8(8.08%) |
99(38.08%) |
36 and above |
146(90.68%) |
15(9.32%) |
161(61.92%) |
Education of mother |
|
|
|
χ2=1.75, p-0.186, d.f=1 |
Till middle school |
137(93.20%) |
10(6.80%) |
147(56.54%) |
High school and above |
100(88.50%) |
13(11.50%) |
113(43.46%) |
Education of the father |
|
|
|
χ2=0.168, p-0.897, d.f=1 |
Till primary school |
127(91.37%) |
12(8.63%) |
139(53.46%) |
Middle school and above |
110(90.91%) |
11(9.09%) |
121(46.54%) |
Occupation of the mother |
|
|
|
χ2=0.683, p-0.408, d.f=1 |
Home maker |
183(91.96%) |
16(8.04%) |
199(76.54%) |
Employed |
54(88.52%) |
7(11.48%) |
61(23.46%) |
Type of family |
|
|
|
χ2=1.43, p-0.231, d.f=1 |
Nuclear |
190(92.23%) |
16(7.77%) |
206(79.23%) |
Joint |
47(87.04%) |
7(12.96%) |
54(20.77%) |
Religion |
|
|
|
χ2=0.853, p-0.977, d.f=1 |
Hindus |
227(91.16%) |
22(8.84%) |
249(95.77%) |
Non-Hindus |
10(90.91%) |
1(9.09%) |
11(4.23%) |
Total no. of children |
|
|
|
χ2=0.551, p-0.458, d.f=1 |
Two and less |
216(90.76%) |
22(9.24%) |
238(91.54%) |
Three and above |
21(95.45%) |
1(4.55%) |
22(8.46%) |
Sex of the child |
|
|
|
χ2=0.351, p-0.553, d.f=1 |
Male |
129(90.21%) |
14(9.79%) |
143(55.00%) |
Female |
108(92.31%) |
9(7.69%) |
117(45.00%) |
Age in months |
|
|
|
χ2=0.222, p-0.882, d.f=1 |
24 months and below |
89(90.82%) |
9(9.18%) |
98(37.69%) |
25-60 months |
148(91.36%) |
14(8.64%) |
162(62.31%) |
Order of birth |
|
|
|
χ2=0.708, p-0.400, d.f=1 |
1st order |
133(89.86%) |
15(10.14%) |
148(56.92%) |
2nd order and above |
104(92.86%) |
8(7.14%) |
112(43.08%) |
During the previous six months duration, all the children in the study population had one or other illnesses. Prevalence of common childhood illness among the study population of aged under five years in previous six months were 93.46% for acute respiratory illness, 77.69% for diarrhea, and 69.23% for fever. Prevalence was 80.13% for combined childhood illnesses.
All the sick children were taken to health facility irrespective of the type of illnesses and the time interval between the onset of illness and seeking health care ranges from immediate to two days of onset. All the mothers cited age of the patient being very young as the main criterion for seeking immediate health care services. None of them practiced self medication. Majority of them sought treatment immediately after onset of illness; 91.01% for ADD, 91% for ARI and 90.45% for fever. Most of them sought treatment from private hospitals; 79.78% for ADD, 78.67% for ARI and 80.89% for fever. For combined childhood illnesses, altogether 90.82% sought health care immediately. Among those children who had diarrhea (n-202), majority of them (95.05%) were given oral rehydration solution. About 7.03% of the sick children were taken to second hospital facility due to dissatisfaction in the initial hospitals.
Regarding source of information of the hospital, 95% of the mother got information about the hospital on their own, and 5% of them received information from neighbors. About 9.23% (n-24) of the study group was hospitalized in the previous six months for various illnesses. Major reason for hospitalization was ADD (30%), followed by ARI (15%), fever (10%), febrile seizures (15%), vomiting (15%), burns (10%) and dog bite (5%). Majority (83.33%) got admitted in private hospitals and 16.67% got inpatient treatment from government hospitals. Almost half of them (41.67%) got admitted on the same day of onset of illness and an equal percentage of sick children stayed in the hospital for 5-10 days. Average length of stay in the hospital was 6.92 days.
Discussion
Many studies on health care seeking for childhood illnesses so far focused on rural or urban population, only few carried out their study on fishermen community both in India and around the world.
This study to assess the health seeking behaviour of parents of children under five years of age in a fishermen community found that, majority (82.69%) were registered in the ICDS and at least 68.65% were getting one or other services from ICDS. This finding was comparatively high than the national level finding from NFHS-III survey, which documented that only 33% were receiving some kind of services from ICDS.(8)
In our study, the percentage of children under five years with age appropriate immunization coverage was 94.23% and when compared to NFHS-III survey report finding of national (43.3%) and state level (80.5%), our finding was quite satisfactory.(8) But the findings from the slum area of Maharashtra revealed different picture where they noted that 64.28% of the children under five years were fully immunized up to date, 25.95% were partially immunized and 9.76% were unimmunized.(5) Majority of our study population (85%) received vaccination from government facilities, but in Madhya Pradesh study they reported that in their study population, only 54% immunized from government hospitals.(10)
Major reason mentioned for delayed vaccination in Maharashtra study was lack of knowledge on immunization (36.67%) but contrary to this, our study reported that more than one third of the respondents (36.36%) mentioned sickness of the child as the main reason for delayed vaccination.[5] Another study from Andhra Pradesh reported that ignorance (51.8%) and illness of the child at the due time of vaccination (31.9%) were the major reasons for delayed immunization.(11)
Allopathy medicine was the preferred system of medicine among all the mothers of the study population. Similar observation was documented in Pondicherry studywhich was conducted among fishermen community.(12) While majority of the parents in our study utilized government facilities for immunization, but for consultation during illness of their children about 81.15% sought private health care services.However, other Fishermen based studies from Pondicherry, Orissa and Gujarat revealed that 65%, 41.7% and 35.61% sought private health care respectively.(12-14) A study in Nicaragua found that 75% utilized public health facilities for health care. In our study, geographical distance (75.36%) and good treatment (14.22%) were the key reasons cited by the mothers for choosing private health care services.(15)
During the previous six months duration, all the children in our study population had one or other illnesses and the prevalence of common childhood illness among the study population of children aged under five years in previous six months were 93.46% for acute respiratory illness, 77.69% for diarrhea, and 69.23% for fever. Overall prevalence was 80.13% for all childhood illnesses. Similar observation was noted in a study from Bhopal which reported the prevalence of 63.86% for diarrhea and 96.71% for ARI in the previous six months.(16) In Ethiopian study, the overall prevalence was 26.5% for all childhood illnesses in the previous two weeks.(17) But the observations from Pondicherry studyamong fishermen communitywas different which reported the combined prevalence of childhood illnesses as 14% with ARI (5.6%), acute diarrhea (4.75%) and fever (3.7%) in the previous two weeks duration.(12) In Vietnam study, they found that prevalence of respiratory infection and diarrhea was 31% and 11% respectively in the previous four weeks.(18) The higher prevalence of illnesses in our study could be due to longer recall period (6 months), poor environmental condition and improper cooking practices.
It was overwhelming to found that all the sick children were taken to health facility irrespective of the type of illnesses. But in UNICEF study conducted in India reported only 74% with diarrhea in the previous two weeks were taken to the hospitals.(19) Similarly, in Sierra Leone study, 85% of the children were brought to the health facility for any illnesses but in Yemen, the rate was quite lower, it revealed that only 51.42% sought medical care for sick children.(20-21) This wide variation in seeking health care could be due to different health seeking behaviour in different population, greater awareness in certain region and availability of accessible and affordable health care services.
Regarding self medication, none of our respondents practiced self medication, studies from Yemen, Somalia, Western Kenya, Vietnam and Nepal reported that 7.7%, 25%, 32.4% 56% and 61.3% of them self medicated their sick child. This vast difference might be due to different cultural practices in different countries, comparison of developing country’s estimates with under developed countries, and war related issues.(18,21-24)
On studying the time interval between the onset of illness and seeking health care in our study found that time interval ranges from immediate to two days of onset of illness. In our study, about 90.82% took their child immediately to health care services after the onset of illness. Fishermen based study in Gujarat found that only 28.9% of the mothers visited the doctor on the very first day of illness and another hospital based study in Gwalior among children below three years of age with acute respiratory symptoms found that 49.7% of them sought health care after one week of symptom onset, 36.7% sought treatment in between two to one week of onset of symptoms.(13,25)
Regarding fever, majority of our mothers (90.45%) sought immediate health care services. But the observation from Tanzania study reported that only16.8% of children were taken to the hospital on the same day of onset of fever.(26) In Bangladesh study, only 58% were taken to trained health provider, within 48 hours of onset of fever.(27) Our estimates on ARI, revealed that of all of them who sought health care services, nearly 91% sought immediate care, but in rural Bangladesh study it was documented that only 48% sought direct hospital care. About 7.03% of the sick children were taken to second hospital facility due to dissatisfaction in the initial hospitals.(28)
According to World Health Organization, oral rehydration solution prepared from ORS salt and zinc administration was recommended for management of diarrheal diseases. In our study, majority of the children who had diarrhea in the previous six months (95.05%) were given oral rehydration solution prepared from ORS salt. Our estimates of administration of ORS were quite high compared to NFHS-III survey reports with national average of 26% and state average of 29% among children under three years age for previous two weeks and also UNICEFF survey finding which reported only 38% of the mother administered ORS to their child with diarrhea.(18,19) This difference could be due to different recall period, age group covered and geographical variation in health seeking behaviors. But unfortunately no one was aware of zinc administration for their children during diarrheal episodes.
Analysis of health seeking behaviors like preference for type of health facility and time interval for seeking health care with their socio-demographic variables revealed no association between them. Similar findings were reported in Pondicherry studywherethey reported that health seeking preference of either private or government health facility were not significantly associated with gender of the child, birth order and maternal education.(12) On the other hand in West Bengal study, they found that gender of the children and educational statuses of the mother were significantly associated with health seeking behaviour.(29) Similarly, in Bangladesh study, they observed that gender, educational status of the father, and younger children (< 2 years) were associated significantly with health seeking behaviour.(27) In Nigerian study, age of the mother was significantly associated with health seeking behaviour.(30)
About 9.23% of the study group was hospitalized in the previous six months for various illnesses. Nearly one fourth of the hospitalized children (30%) got admitted for acute diarrheal disease. Our finding was high than the hospital admission rate for diarrhea in Brazil where they reported 8.4% among children with ADD.(31) Similarly in a hospital based study done in Kolkata, leading cause of hospitalization was acute respiratory infection (17.52%), but diarrheal disease constituted 7.83% of total hospitalized children. In Kolkata study, average length of stay in the hospital was 6.3 days per patient; similar observation was noted in our study too, the average length of stay was 6.92 days.(32)
Conclusion
This study found that immunization status was age appropriate for majority of the study population, and 85% received vaccination from government facilities. Prevalence of combined childhood illnesses was 80.13% for the previous six months. Even though, all the study population fell under class III socio-economic classification according to modified B.G. Prasad classification, majority of the sick children (81.15%) were taken to private hospitals for treatment citing geographical distance (75.36%) as the main reason. Majority of the respondents (90.82%) took their sick children immediately after onset of illness citing age of the patient as the reason. In this regard, it must be noted although the health seeking behaviour was quite satisfactory, the prevalence of childhood illnesses was high in this specific population and utilization of public health facility was less, hence further studies should be carried out to assess the factors associated with high prevalence in this specific population and moreover steps to be taken to improve the utilization of government health facility.
Ackknowledgement
We were extremely thankful for Indian Council for Medical Research (ICMR) for their encouragement and support.
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